Anaemia in pregnancy

Dr varsha deshmukh

Asso prof & unit incharge

Govt medical college

aurangabad

Magnitude of problem

• Globally, is about 30 %• In developing countries & India,

incidence is around 40 – 90%.• Responsible for 40% of maternal deaths

in third world countries.• Important cause of direct and

indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127

Indian scenario

• 87% indian pregnant women are anaemic

• 46%-urban area

• 10%-severely anaemic

• (ICMR 2000)

• Direct death caused-20%(MMR)

• ASSO CAUSE-17-47%(ICMR 2000)

DEFINITION• Anemia - insufficient Hb to carry out O2

requirement by tissues.

• WHO definition : Hb conc. < 11 gm %

• CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimeste WHO technical report Series no. 405, Geneva

1968For developing countries : cut off level suggested is 10 gm %

Centre for disease control, MMWR 1989;38:400-4

Degree Hb% Haematocrit (%)

Moderate 7-10.9 24-37%

Severe 4-6.9 13-23%

Very Severe <4 <13%

Degree Hb% Haematocrit (%)

Moderate 7-10.9 24-37%

Severe 4-6.9 13-23%

Very Severe <4 <13%

Irritability

Fatigue

Weakness

Lack of Concentration

Infection

Palpitation

Symptoms

Pallor of skin And m/m

Edema

PlatynychiaKoilonychia PlatynychiaKoilonychia

Glossitis

Stomatitis

Tachycardi

a

Soft ejectionsystolic murmur

Signs

Causes of anaemia

Physiological

Pathological

• Nutritional

• Haemorrhagic

• Haemolytic

Causes of anaemia

• Low socioeconomic status and poor hygiene

• Chronic malnutrition

• Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos

• GI infections and infestations (e.g. Kala azar, worm infestations)

Fetal Iron Stores

Infancy (92%)

Pre school (70%)

Adolescent (55 - 95%)

Adult women (60%)

Pregnancy (80%)

+ Menstruation

Causes of anaemia• Poor pre-pregnancy iron balance due to –

untreated systemic diseases & menstrual disorders

• Improper supplementation of iron in pregnancy ( late registration and poor follow up)

• Repeated childbearing• Lack of awareness and illliteracy

Effect of anaemia in preg

IUGR

IUD IUH

CCF

INFECTION

PRETERM LABOUR

PIH

Medical Disorder

Iron loss @ absorptionIron Absorption Iron Absorption ∝∝ 1

Amount of iron in the body

Iron Loss

Skin

Urine

Feces

Menstruation

1-2mg/d

20-30mg/c

Iron absorption

-ve

Iron absorption

↓ Bioavailabil i ty of Iron

-ve-ve

Phosphate phytate

Worm infestation

Normal valuesHb 13.5 – 14 gm %

R.B.C. 4.5 – 4.7 million/cu mm

Serum Iron 50 – 150 μg / dL

TIBC 300 – 360 μg / dL

Transferrin saturation 25 – 50 %

S. Ferritin level 30 μg / Lit

Red Cell protoporphyrin 30 μg / dL

Erythropoietin 15.20 U / Lit

MCV 76 – 100 fL

MCH 27 – 33 pg

MCHC 33.37 gm / dL

PCV 32 – 40 %

diagnosis

EASY TO DIAGNOSE

SIMPLE TO TREAT

Hookworm infestations

♦ Common cause of anaemia in developing countries

♦ Most common – hookworm infestation, Round worm, whip worm, etc.

♦ Oral iron therapy becomes ineffective

♦ Treatment by antihelminthics is a must

Treatment

♦ Mebendazole : 100mg twice daily for three days

♦ Pyrantel pamoate : 10mg / kg in single dose.

♦ Albendazole : 400mg once a day for three days

Treatment of iron def anaemia

FS + FA

Pregnancy

Lactating mothers

Family planning acceptors

Children – 1 to 11 years

prevention

Pre – pregnancy :

• Treat the cause before conception

• Pre-pregnancy balanced diet, education

and health support.

• Build up iron stores during adolescent

phase

Iron supplementation• Ideal dose – 100mg per day (prophylactic)

• Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate

• Rise in Hb – 0.8 gm / dl / week

• Side effects -G I upset most common

• Pt. compliance not guaranteed

• Ineffective in pts with worm infestations

• Inconclusive evidence on benefit of controlled release Iron preparation

Types of iron preparations

Oral IronBlood

transfusionParenteral

Parenteral iron therapy

100 mg elemental Iron

Anaphylactic Anaphylactic reactionreaction

Anaphylactic Anaphylactic reactionreaction

I.M. I.V.

Indications of parenteral therpy

• Intolerance to oral iron

• Poor compliance to oral iron

• Gastrointestinal disorders

• Malabsorption syndromes

• Rapid blood loss

Indications of parenteral therapy

• Inability to maintain iron balance (haemodialysis)

• Patient donating large amount of blood

for auto-transfusion programme

• ? Pregnant women with severe IDA, presenting late in pregnancy

Folic acid deficiency

Special considerations in diagnosis

• FDA is suspected when the expected response

to adequate iron therapy is not achieved

• Macrocytosis can occur in pregnancy in absence

of FDA

• If FDA + IDA present, it will be masked by IDA

• Definitive diagnosis – Bone marrow aspirate

• HB estimation

• Peripheral smear

• MCV estimation

• Serum folate

• Red cell folate

• FIGLU estimations

• Marrow aspirate

Folic acid deficiency

Folic acid deficiency

♦ Strong case for routine prophylaxis

♦ Prophylaxis with anti convulsants

♦ Continue routine oral therapy for

hemolytic anaemia

♦ Parenteral therapy for severe deficiency

Blood transfusion

‘‘ transfusion should be transfusion should be prescribed prescribed ONLYONLY for for

condit ions for which there is condit ions for which there is NONO OTHER TREATMENT’ OTHER TREATMENT’

♦ Anaemia although preventable is a global

problem

♦ Anaemia still is the commonest cause of maternal

mortality and morbidity in spite of easy diagnosis

and treatment

♦ Anaemia can be due to a number of causes,

including certain diseases or a shortage of iron,

folic

acid or Vitamin B12.

♦ The most common cause of anemia in pregnancy

is

iron deficiency.

♦ Iron therapy is best given orally

Take Home Message

• The youth need to be educated about diet, sanitation and personal hygiene

• Hookworm infestation should be treated

• Pregnant women should be given Iron and folate supplements

Take Home Message